Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: https://www.tandfonline.com/loi/imte20

Curriculum integration: From Ladder to Ludo

Ahsan Sethi & Rehan Ahmed Khan

To cite this article: Ahsan Sethi & Rehan Ahmed Khan (2019): Curriculum integration: From
Ladder to Ludo, Medical Teacher, DOI: 10.1080/0142159X.2019.1707176

To link to this article: https://doi.org/10.1080/0142159X.2019.1707176

Published online: 27 Dec 2019.

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MEDICAL TEACHER
https://doi.org/10.1080/0142159X.2019.1707176

PERSONAL VIEW

Curriculum integration: From Ladder to Ludo

Ahsan Sethia,b and Rehan Ahmed Khanc
a
Institute of Health Professions Education and Research, Khyber Medical University, Peshawar, Pakistan; bCentre for Medical Education,
University of Dundee, Dundee, UK; cIslamic International Medical College, Riphah International University, Rawalpindi, Pakistan

ABSTRACT KEYWORDS
This Personal View is based on our experiences with the levels of integration. We are concerned Curriculum; integration;
about the (mis) interpretation of ‘integration ladder’ in our context and propose directions for medical; education
rethinking curriculum integration. We share the famous board game ‘Ludo’ as a metaphor to under-
stand the concept of integration. Mughal emperors (educators) played (lead) Ludo (curriculum/teach-
ing reforms) in which tokens (disciplines) move from their silos (departments) towards others
(integrate) according to rolls of a dice (resources) and not stepwise (1-2-3 … 11) like in a ladder.
There are safe spaces (timetable/minimum hours), double pieces (combination of different integra-
tion levels) and tokens (disciplines) can also be pushed back to their silos by opponents (challenges).
The game (change management) involves skill (competence in medical education), strategy (plan-
ning), emotion (emotional intelligence) and luck. We found Ludo relevant to understanding integra-
tion and discuss three different systems with implications on the curriculum, assessment,
organisational structure and timetable/schedules. We believe that a clear description of integration
as three different systems will counter the issues with the integration ladder and make it easier for
institutions and educationists to understand, opt for and implement curriculum integration.

Under Flexner’s influence, medical curricula around the
world came to be structured into: Preclinical medicine
learned in lecture theatres, laboratories, dissecting rooms,
libraries and Clinical medicine learned in wards and operat-
ing theatres of teaching hospitals. Most of the medical col-
leges in Pakistan are following the traditional system that
is teacher centered, discipline based and opportunistic. As
the move towards adopting integrated curriculum is gath-
ering momentum world-wide, several medical institutions
with established curricula are finding it hard to make the
change (Malik and Malik 2011).
There is no single universally accepted curriculum. Six
educational strategies, SPICES have been identified in relation
to curriculum in medical schools by Harden et al. (1984). One
of the key element in the SPICES curriculum model is inte-
gration (Harden et al. 1984). Curriculum integration involves
the organization of teaching to interrelate or unify subjects
frequently taught in separate academic courses or depart-
ments (Harden 2000). Integration is an important means of
dealing with overload of information, fragmented teaching
of basic and clinical sciences, and the need for relevant and
meaningful learning (Yamani and Rahimi 2016).
To aid planning, implementing and evaluating medical
curricula, Harden (2000) proposed a ladder with 11 levels
of integration, which received a lot of attention (449þ
Citations). As medical educationists, we have observed an
extensive debate on these levels of integration. The various
colleges request for one specific level of integration for
their curriculum and boast about them in annual reports,
blogs and scientific meetings (Harden 2013). These levels
are seen as a marker of quality and criterion for assessing
the degree of innovation in a medical curriculum. These
levels have become so popular that some regulatory
bodies including Pakistan Medical and Dental Council have
adopted and recommended level 5 as their minimum cur-
riculum requirements. However, we know that a straitjacket
approach towards curriculum integration may not achieve
desirable results. To decide the level of integration, it is
necessary to take into account the institution’s aims and
objectives, resources, infrastructure and assessment meth-
ods (Harden 2000). Even when all these factors are taken
into consideration, it may not be possible to achieve the
same level of integration in all areas of the curriculum. The
integration level may be different in every module and also
within a module (Bleakley 2012). Therefore, regulatory
bodies including Liaison Committee on Medical Education,
General Medical Council, World Federation for Medical
Education have refrained from specifying any levels for
integration as their curriculum framework/standard.
However, they did encourage integration both horizontally
among basic biomedical, behavioral and social sciences
and vertical integration with clinical sciences.
Malik and Malik (2011) observed that interpretation of
‘integration’ varies in different institutions and among indi-
viduals. Here we discussed how integration ladder has
been misinterpreted in our context and propose directions
for rethinking curriculum integration. (1) We have wit-
nessed faculty considering ‘Isolation’ as a form of integra-
tion. They frequently refer to this being mentioned as the
first step in the integration ladder. This becomes problem-
atic when they report subjects taught in isolation as a form
of integration when writing self-assessment reports for
accreditation purpose, whereas we know that this level
involves no integration. So, this raises a question if this

CONTACT Ahsan Sethi ahsansethi@gmail.com Institute of Health Professions Education and Research, Khyber Medical University, Hayatabad Phase 5,
Peshawar, Pakistan
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 A. SETHI AND R. A. KHAN
should be a step on the integration ladder? (2) We believe
that the number of steps on a ladder increases its sensitiv-
ity, but practically speaking, the relevance of each step has
been minimised with too small differences on some steps
which may be difficult to interpret. These steps on a ladder
overlap and have vague boundaries – the term ‘may be’
has been used quite a few times by Harden (2000) to
explain aspects of these different levels, which is also sug-
gestive of that. (3) We believe that level 4 is not for fully
integrated overall programme per se but involves nesting
of some content within any discipline. (4) We argue that
minimum integration starts at level 5 ‘Temporal coordin-
ation’ and the steps below this level do not accurately rep-
resent the essence of integration. (5) Also, Level 6 ‘Sharing’
in which two disciplines may design a joint teaching pro-
gramme course and can be an end in itself. As Harden
states that this level might be a standalone example of a
special course and this is not necessarily to be followed in
other parts of the curriculum as a level of integration. (6) A
ladder always needs to be climbed up so its steps give an
impression that curriculum needs to follow the similar
‘Climbing up pattern’. One has to climb one step at a time
and stay at one step at a time. This is not true with regards
to our experience in curriculum reforms, we have observed
institutions moving from Level 1 to Level 7 or even 9 with-
out passing through other levels. Also, different profes-
sional years in an MBBS (MBChB) programme may have
different levels of integrations. For example, the early years
may have a Multidisciplinary (Level 9) format, i.e. theme-
based modular curriculum, while the final professional year
is designed as Transdisciplinary (Level 11). (7) We also feel
that the examples given by Harden (2000) for each level of
integration are appropriate to a certain level and can only
be considered in that particular context. For example, one
can only apply level 11 in the late clinical years and not
early on in the curriculum. (8) Going up the level is sug-
gestive that the curriculum is improving as well as the edu-
cational standards, which is also misleading. Based on
these observations, we believe that there should be no lev-
els of integration as there is no evidence that one level is
better than the other. Therefore, we propose three systems
of integration to help understand its essence, along with
defining characteristics for implementation.
We share the famous board game ‘Ludo’ as a metaphor to
understand the concept of integration. Mughal emperors
(educators) played (lead) Ludo (curriculum/teaching reforms)
in which tokens (disciplines) move from their silos (depart-
ments) towards others (integrate) according to rolls of a dice
(resources) and not stepwise (1-2-3 … 11) like in a ladder.
There are safe spaces (timetable/minimum hours), double
pieces (combination of different integration levels) and tokens
(disciplines) can also be pushed back to their silos by oppo-
nents (challenges). The game (change management) involves
skill (competence in medical education), strategy (planning),
emotion (emotional intelligence) and luck (Sethi et al. 2016).
We found Ludo relevant to understanding integration and its
implications on the curriculum, assessment, organisational
structure and timetable/schedules. To encompass various
integration levels for ease of understanding and application
by novices to integrate their existing curriculum, lets replace
‘Ladder’ with a ‘Ludo’ having three broad systems: (a) System I
– Intradepartmental Integration, where the faculty from a
single discipline identify specific, relevant and sometimes
applied contents from other disciplines and embed it within
their discipline, e.g. asking students to measure blood pres-
sure as Physiology practical to discuss the underpinning con-
cepts of blood physiology. This system does not result in
greater changes in the curriculum organisation, organisational
structure and timetable from that in traditional discipline-
based curriculum. (b) System II – Interdepartmental
Integration, a few disciplines integrate with each other. This
may or may not be around body systems or organs, e.g. teach-
ing the anatomy, physiology, biochemistry, pathology, medi-
cine and surgery of heart within a single cardiovascular
module. This system has an impact on organisational struc-
ture, which changes from discipline based to modular com-
mittees, timetable contains mention of both the discipline
and related topics organized around themes and each assess-
ment comprises of questions from different disciplines. (c)
System III – Consolidation; here the disciplines dissolve com-
pletely around themes based on predefined clinical presenta-
tions or problems, e.g. teaching the anatomy, physiology,
biochemistry, pathology, medicine and surgery underpinning
chest pain across different genders and life cycle/age-groups.
This system reflects ‘Transdisciplinary’ level of integration lad-
der with learning organised around real-world clinical presen-
tations or problems. The learner integrates internally, and
intrinsically different experiences gained in various clinical
and community attachments to achieve mastery of the com-
petencies self-directedly. The learner takes more responsibility
for the integration and is given the tools to do so. The time-
table only mentions the clinical attachments schedule. We
believe that this clear description of integration as three differ-
ent systems will counter the issues with the integration lad-
der. These systems are not meant for downplaying the
integration ladder, which is a foundational work on integra-
tion and this paper. However, these systems intend to make it
easier for institutions and educationists to understand, opt for
and implement curriculum integration.
Acknowledgements
We would like to thank our health professions education colleagues
and students for their helpful comments in the writing process.
Disclosure statement
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the article.
Notes on contributors
Dr. Ahsan Sethi, BDS, MPH, MMEd, FHEA, MAcadMEd, FDTFEd, PhD, is
an Assistant Professor in the Institute of Health Professions Education
and Research at the Khyber Medical University, Pakistan and part-time
tutor at Centre for Medical Education, University of Dundee,
United Kingdom.
Dr. Rehan Ahmed Khan, MBBS, FCPS, FRCS, JM-HPE, MHPE, is the
Professor of Surgery at Islamic International Medical College, Riphah
International University, Pakistan.
ORCID
Ahsan Sethi http://orcid.org/0000-0001-9176-3254
Rehan Ahmed Khan http://orcid.org/0000-0002-8045-1471

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